Acute Pancreatitis

Pancreatitis is inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenum—the first part of the small intestine. The pancreas secretes digestive juices, or enzymes, into the duodenum through a tube called the pancreatic duct. Pancreatic enzymes join with bile—a liquid produced in the liver and stored in the gallbladder—to digest food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body regulate the glucose it takes from food for energy.

Normally, digestive enzymes secreted by the pancreas do not become active until they reach the small intestine. But when the pancreas is inflamed, the enzymes inside it attack and damage the tissues that produce them.

Surgeons in the Complex Abdominal Surgery Program at UCSF Medical Center have developed surgical techniques for severe acute pancreatitis, including blunt necrosectomy and the minimally invasive, step-up necrosectomy to remove the dead tissue. With new techniques to manage the disease, these procedures result in decreased severity of illness and fewer deaths. The death rate of patients with severe acute pancreatitis at UCSF is two to three times less than the national average.

Pancreatitis can be acute or chronic. Either form is serious and can lead to complications. In severe cases, bleeding, infection, and permanent tissue damage may occur.

Both forms of pancreatitis occur more often in men than women.

Acute Pancreatitis

Acute pancreatitis is inflammation of the pancreas that occurs suddenly and usually resolves in a few days with treatment. Acute pancreatitis can be a life-threatening illness with severe complications. Each year, about 210,000 people in the United States are admitted to the hospital with acute pancreatitis.¹ The most common cause of acute pancreatitis is the presence of gallstones-small, pebble-like substances made of hardened bile-that cause inflammation in the pancreas as they pass through the common bile duct. Chronic, heavy alcohol use is also a common cause. Acute pancreatitis can occur within hours or as long as 2 days after consuming alcohol. Other causes of acute pancreatitis include abdominal trauma, medications, infections, tumors, and genetic abnormalities of the pancreas.

Symptoms

Acute pancreatitis usually begins with gradual or sudden pain in the upper abdomen that sometimes extends through the back. The pain may be mild at first and feel worse after eating. But the pain is often severe and may become constant and last for several days. A person with acute pancreatitis usually looks and feels very ill and needs immediate medical attention. Other symptoms may include

• a swollen and tender abdomen
• nausea and vomiting
• fever
• a rapid pulse

Severe acute pancreatitis may cause dehydration and low blood pressure. The heart, lungs, or kidneys can fail. If bleeding occurs in the pancreas, shock and even death may follow.

Diagnosis

While asking about a person's medical history and conducting a thorough physical examination, the doctor will order a blood test to assist in the diagnosis. During acute pancreatitis, the blood contains at least three times the normal amount of amylase and lipase, digestive enzymes formed in the pancreas. Changes may also occur in other body chemicals such as glucose, calcium, magnesium, sodium, potassium, and bicarbonate. After the person's condition improves, the levels usually return to normal.

Diagnosing acute pancreatitis is often difficult because of the deep location of the pancreas. The doctor will likely order one or more of the following tests:

• Abdominal ultrasound. Sound waves are sent toward the pancreas through a handheld device that a technician glides over the abdomen. The sound waves bounce off the pancreas, gallbladder, liver, and other organs, and their echoes make electrical impulses that create a picture-called a sonogram-on a video monitor. If gallstones are causing inflammation, the sound waves will also bounce off them, showing their location.

• Computerized tomography (CT) scan. The CT scan is a noninvasive x ray that produces three-dimensional pictures of parts of the body. The person lies on a table that slides into a donut-shaped machine. The test may show gallstones and the extent of damage to the pancreas.

• Endoscopic ultrasound (EUS). After spraying a solution to numb the patient's throat, the doctor inserts an endoscope-a thin, flexible, lighted tube-down the throat, through the stomach, and into the small intestine. The doctor turns on an ultrasound attachment to the scope that produces sound waves to create visual images of the pancreas and bile ducts.

• Magnetic resonance cholangiopancreatography (MRCP). MRCP uses magnetic resonance imaging, a noninvasive test that produces cross-section images of parts of the body. After being lightly sedated, the patient lies in a cylinder-like tube for the test. The technician injects dye into the patient's veins that helps show the pancreas, gallbladder, and pancreatic and bile ducts.

• Endoscopic retrograde cholangiopancreatography (ERCP), may determine if there is a bile duct obstruction. During this procedure, a flexible tube is inserted down the throat into the stomach and small intestines. Dye is injected into the drainage tube of the pancreas to locate a possible obstruction.

Treatment

Treatment for acute pancreatitis requires a few days' stay in the hospital for intravenous (IV) fluids, antibiotics, and medication to relieve pain. The person cannot eat or drink so the pancreas can rest. If vomiting occurs, a tube may be placed through the nose and into the stomach to remove fluid and air.

Unless complications arise, acute pancreatitis usually resolves in a few days. In severe cases, the person may require nasogastric feeding-a special liquid given in a long, thin tube inserted through the nose and throat and into the stomach-for several weeks while the pancreas heals.

Before leaving the hospital, the person will be advised not to smoke, drink alcoholic beverages, or eat fatty meals. In some cases, the cause of the pancreatitis is clear, but in others, more tests are needed after the person is discharged and the pancreas is healed.

Soon after a person is admitted to the hospital with suspected narrowing of the pancreatic duct or bile ducts, a physician with specialized training performs ERCP.

After lightly sedating the patient and giving medication to numb the throat, the doctor inserts an endoscope-a long, flexible, lighted tube with a camera-through the mouth, throat, and stomach into the small intestine. The endoscope is connected to a computer and screen. The doctor guides the endoscope and injects a special dye into the pancreatic or bile ducts that helps the pancreas, gallbladder, and bile ducts appear on the screen while x rays are taken.

The following procedures can be performed using ERCP:

Sphincterotomy. Using a small wire on the endoscope, the doctor finds the muscle that surrounds the pancreatic duct or bile ducts and makes a tiny cut to enlarge the duct opening. When a pseudocyst is present, the duct is drained.

Gallstone removal. The endoscope is used to remove pancreatic or bile duct stones with a tiny basket. Gallstone removal is sometimes performed along with a sphincterotomy.

Stent placement. Using the endoscope, the doctor places a tiny piece of plastic or metal that looks like a straw in a narrowed pancreatic or bile duct to keep it open.

Balloon dilatation. Some endoscopes have a small balloon that the doctor uses to dilate, or stretch, a narrowed pancreatic or bile duct. A temporary stent may be placed for a few months to keep the duct open.

People who undergo therapeutic ERCP are at slight risk for complications, including severe pancreatitis, infection, bowel perforation, or bleeding. Complications of ERCP are more common in people with acute or recurrent pancreatitis. A patient who experiences fever, trouble swallowing, or increased throat, chest, or abdominal pain after the procedure should notify a doctor immediately.

Surgery

Surgery may be needed if complications such as infection, cysts or bleeding occur. If gallstones are the cause of your attack, the gallbladder may be removed.

If a bile duct obstruction is suspected of causing the pancreatitis, a procedure called an endoscopic retrograde cholangiopancreatography (ERCP) may be performed. A flexible tube is inserted down the throat into the stomach and small intestines. Dye is injected into the drainage tube of the pancreas to locate the possible obstruction. Special instruments are inserted through the endoscope or tube to remove the obstruction or stretch a narrowing segment of the bile duct.

Patients with severe acute pancreatitis may develop pancreatic necrosis, a serious infection in which tissue within the pancreas dies and later becomes infected. This results in a condition called acute necrotizing pancreatitis. An abscess may form on the dead tissue several weeks after an attack of acute necrotizing pancreatitis.

Patients with severe acute pancreatitis have an average hospital stay of two months, followed by a lengthy recovery period.

Our team of specialists — including those in gastrointestinal surgery, nursing, nutrition, intensive-care medicine, wound care, plastic surgery, pharmacology and infectious disease — work together to customize a treatment plan for each patient.